Iron therapy

Factors affecting iron absorption:

1- Increase by:
a.↑ requirements.
b. anemia.
c. Hcl (for ionization).
d. vit C (reducing agent).
e. amino acids.
2- Decrease by:
a. P04.
b. Oxalates.
c. phytic acid.
d. Tannins.
e. antacids, tetracyclines.
Heme iron in hemoglobin &
myoglobin of red meat is absorbed
intact.

Indications of Fe therapy:
1- ↑ Demands e.g. pregnancy, premature
infants, children and adolescents.
2- Fe deficiency anemia due to chronic blood
loss e.g. GIT bleeding and heavy menses.
3- Malabsoption syndrome & after
gastrectomy.
4- During severe pernicious anemia with Vit.
B12 (iron stores are depleted by sudden ↑ in
blood formation).

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 Oral iron preparations
After meals, till normal hemoglobin and 2
months later to replenish stores.
1- Fe+2 S04: 300mg.
2- Fe +2 gluconate.
3- Fe +2 fumarate.

Causes of failure of oral Fe

therapy:
1- Non compliance.
2- Wrong diagnosis.
3- Continuous blood
loss.
4- Malabsorption &
gastric resection.
5- Chronic renal failure, chronic infection &
malignancy (↓erythropoiesis).

Adverse effects:
1- GIT: nausea, pain & constipation (Fe is
given after meals).
3- Black stools.
4- Stain teeth.
5- Hemosidrosis.
6- Acute toxicity →VD, bloody diarrhea&
vomiting → shock.

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 Parenteral iron therapy
Calculation of total IV iron required:
To correct and replenish stores:
Hb deficit (Normal - pt.)
(gm /100ml blood) X 0.25

Indications:
A) Causes of failure of
oral Fe..........
B) Adverse effects of oral
Fe..........

Preparations:
1) Iron- dextran: by intermittent IVI but mainly by
total dose infusion (TD1). Also by IMI (50
mg/ml).
Advantages of TDI:
1- Patient compliance.
2- Complete iron deficiency correction at one
time.
3- Avoids side effects of IMI.
Other preparations are given only IV, with less
allergy:
2) Sodium ferric gluconate complex.
3) Iron sucrose.
4) Ferric carboxymaltose.

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Adverse effects:
IM:
1- Painful injection.
2- Stain site of injection (brown).
IV& IM:
1- ↓B.P.
2- Headache, backache & arthralgia.
3- Dizziness.
4- Allergy, fever & anaphylactic shock.

Precautions:
1. Used only when absolutely indicated.
2. Calculated dose is diluted in 1 liter saline or
5% dextrose.
3. Antihistaminics are given 30 min. before iron
dose.
4. Test dose is given 1st. Rest of dose is given
over 2-6 hs.

Treatment of acute iron poisoning

1- Deferoxamine : chelating agent: 1gm /12 hrs.
1M or IV.
2- Raw egg and milk.
3- Gastric lavage.
4- NaHC03 (↓ Fe solubility).
5- Deferoxamine by gavage 5gm in l00mI
H20.
6- IV fluids (saline, glucose or alkaline
salt).
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ttt of chronic Fe toxicity (hemochromatosis
or hemosiderosis):
1- Deferoxamine: 1M or SC.
2- Venesection.
3- ↑tea (tannins) intake.

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 Megaloblastic anemia
1- Macrocytic megaloblastic anemia.
2- Achlorhydria & abnormalities in epithelial
tissues.
3- CNS degeneration & polyneuropathy (not in
folic a. deficiency).

A) Intrinsic factor deficiency (Pernicious

anemia)
Causes:
1- Idiopathic: autoimmune.
2- Cancer GIT.
3- Total or partial gastrectomy: involves
parietal cells which secrete intrinsic factor.

B) ↓Vit. B12 absorption by

a ) Inflammatory bowel disease or surgical
resection involving distal ileum (site of vit.
B12 absorption).

b ) Drugs:
1. Biguanides.
2. Colchicine
3. Phenytoin.
4. Neomycin.
Although vit. B12 (extrinsic factor) is supplied
by animal sources, there is no diet deficiency
due to storage in body for years.

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Uses of vit B12:
1. Pernicious anemia (IV).
2. ↓ Vit. Bl2 absorption (oral).
3. Neurological manifestations.
4. Hepatic cirrhosis, polyneuropathy & DM.
In pernicious anemia folic acid alone improves
anemia but worsens nervous complications
(folic a. + B12 are needed together only for
RBCs maturation).

Preparations of B12:
1. Cyanocobalamine: IM initial 1000 μg every
other day for 2 weeks (to replenish stores)
then once weekly till normal blood
picture (for 6 months if neurological
manifestations) then once /month (for life) in
pernicious anemia.
2. Hydroxycobalamine:
-100 ug I.M.
- more bound to plasma proteins
- Long duration
- In tobacco retrobulbar neuritis.
Preferred in pernicious anemia.

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 C) Folic acid deficiency
1. ↓ Diet (fresh fruits & vegetables) supply,
food overcooking & ↑ demand
(pregnancy & lactation) but body stores
(5mg) supply requirements (which are
high) for 2-3 months.
2. Malabsorption.
3. Drugs affecting folate (folic acid):
a. Drugs inhibiting dihydrofolate reductase
enzyme (folic acid antagonists):
1- Trimethoprim. 2- Methotrexate.
3- Antimalarial antifols.
b. Drugs ↓ absorption and storage of folic
acid.
1. Antiepileptic drugs in grand mal epilepsy
as phenytoin.
2. Oral contraceptive pills.
3. Isoniazid.
ttt.: folic acid: oral l mg and IV & 1M leucovorin
(folinic acid) (in no. a above).
N.B. - large amount of folic acid may
counteract antiepileptic effect of drugs.
Uses of folic acid:
1. Megaloblastic 5. Liver diseases &
anemia. hemolytic anemia
2. Malabsorption
syndrome.
3. Pregnancy.
4. With antiepileptics.
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 Hemopoietic growth factors
They are glycoproteins hormones produced by
kidney, Iiver and by DNA recombinant technique
& cloning. Given IV.
e.g. erythropoietin (produced by hypoxia),
myeloid growth factor (colony stimulating
factor) by infection and megakaryocyte growth
factor.

Erythropoietin
Mechanism:
1. Stimulates erythroid
proliferation and differentiation via
specific erythropoietin receptors
on red cell progenitors.
2. ↑reticulocytes release from
bone marrow.

Uses:
1. Aplastic anemia.
2. Anemia of chronic renal failure.
3. ttt. of malignancy by cytotoxic drugs or
irradiation.
4. AIDs.
5. In athletes.

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Adverse effects :
1. Polycythemia (↑ hemopoiesis).
2. Thrombotic complications (↑ blood viscosity):
stroke, MI, DVT.
3. Hypertension.
e.g. epoetin α, epoetin β & darbepoetin.

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 Colony stimulating factors (CSF)
1. Granulocyte CSF (G- CSF).
2. Granulocyte macrophage CSF (GM-CSF).
Mechanism :
1. ↑myeloid proliferation & differentiation via
specific receptors on various myeloid
progenitor cells.
2. ↑phagocytic activity & survival of mature
neutrophils.
3. G- CSF (>GM-CSF) ↑hematopoietic stem cells
from bone marrow.
4. GM-CSF is broader multipotential
hematopoietic growth factor for granulocyte,
erythroid & megakaryocyte progenitors.
Uses:
1. Agranulocytosis by cytotoxic drugs (febrile
neutropenia).
2. After chemotherapy of acute myeloid
leukemia.
3. Autologous stem cell transplantation in high
dose of cytotoxic drugs.
Adverse effects of GM-CSF:
1- Edema.
2- Fever.
3- Allergy.
4- Pleural effusion.
G- CSF is less toxic (causes bone pain).
e.g. of GM- CSF: sargramostim& pegfilgrastim.

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 Megakaryocyte growth factor
Mechanism :
Via cytokine receptors ↑growth of
megakaryocyte progenitors, stimulates mature
megakaryocytes and ↑response of platelets to
various factors.
Uses :
Thrombocytopenia. SC.
e.g.
1. Oprelvekin : recombinant interleukin-II
stimulate growth of multiple lymphoid& myeloid
cells.
2. Romiplostim: activates thrombopoitin
receptors.

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